Des Moines University Clinic Authorization for Release of Medical Information 2013 free printable template

Des Moines University, H.I.M. Dept 3200 Grand Ave., Des Moines, IA 50312 Phone (515) 271-1706 Fax (515) 271-1726 AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION I give permission to use and/or disclose

How to fill out Des Moines University Clinic Authorization for Release

How to fill out Des Moines University Clinic Authorization for Release of Medical

1. Obtain the Authorization for Release of Medical form from Des Moines University Clinic.
2. Fill in your personal information at the top of the form, including your name, address, and date of birth.
3. Specify the types of records you wish to have released (e.g., medical history, treatment records).
4. Indicate the name of the person or organization to whom the information will be sent.
5. Add the purpose of the release, such as 'transition of care' or 'insurance purposes.'
6. Provide the dates of services you are requesting records for, if applicable.
7. Review the form for accuracy and completeness.
8. Sign and date the form to authorize the release.
9. Submit the completed form to the Des Moines University Clinic by mail, fax, or in person.

Who needs Des Moines University Clinic Authorization for Release of Medical?

1. Patients who want to share their medical information with another healthcare provider.
2. Individuals requesting their medical records for personal use or to verify history.
3. Insurance companies that require medical records for claims processing.
4. Legal representatives needing access to a patient's medical information.
5. Patients transferring their care to a new healthcare provider.

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What is Des Moines University Clinic Authorization for Release of Medical?

The Des Moines University Clinic Authorization for Release of Medical is a form that allows patients to authorize the release of their medical records or health information to designated individuals or entities.

Who is required to file Des Moines University Clinic Authorization for Release of Medical?

Patients who wish to share their medical information with other healthcare providers, insurance companies, or third parties are required to file the authorization.

How to fill out Des Moines University Clinic Authorization for Release of Medical?

To fill out the authorization, patients need to provide their personal information, specify the information to be released, indicate the recipient, and sign and date the form.

What is the purpose of Des Moines University Clinic Authorization for Release of Medical?

The purpose of the authorization is to ensure that patients have control over their medical information and can permit its disclosure according to their needs.

What information must be reported on Des Moines University Clinic Authorization for Release of Medical?

The form must include the patient's name, date of birth, the specific information to be released, the name of the individual or entity receiving the information, and the signature of the patient or authorized representative.